thyroidectomy

1. CASE PRESENTATION –
TOTAL THYROIDECTOMY
Presented By : Dr. Nirbhay Shankar Jha
Moderated By : Dr. Salony Agarwal ma’am

2. Name- Sandeep Joshi s/o Mr Ram Kumar Joshi
Age - 47 yrs
Sex – Male
Occupation : farmer
Address – Baghpat, UP
Hospital I.P.D. -210332064
Ward - MSW 2, bed no 2p
Date of admission - 24/02/24

3. CHIEF COMPLAINTS-
Visible swelling in front of the neck since 5 years.
Visible swelling in front of the right clavicle since 4 months
Pain in the right shoulder on and off since 2 and half months.

4. HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 5 years back when he
noticed visible lump in left side of neck .
Swelling was insidious in onset and gradually increased in size . It
was initially around pea size on the left side at the time of first
notice, it progressively increased in size and crossed the midline,
extending towards the right also such that it attained its present
size of an orange in front of the neck.
4 months back patient noticed a swelling in front of the right
clavicle around pea size, gradually increased in size of a lemon,
oval in shape. It was associated with pain which was diffuse in
nature, radiating to shoulder and right side of neck. It was relieved
on taking medication.

5. There is no history of difficulty in breathing while sleeping in
supine position, difficulty in swallowing food or water,
hoarseness of voice
No history of excessive fatigue, heat or cold intolerance,
decreased or increased weight, and increased sweating ,increased
anxiety and palpitations, diarrhoea or constipation or oedema.
No h/o diplopia or any features suggestive of ocular changes

6. • Patient came to surgery OPD on 24/2/2024for the present
complaints
• Patient was investigated and counselled for surgery due to:
i. Large Goitre size
ii. Increasing size of swelling (pain radiating to shoulder &
neck)
iii. Cosmetic

7. PAST HISTORY-
Patient has no h/o drug allergy , chest pain , hypertension, diabetes
mellitus , bleeding disorder, tuberculosis, asthma, jaundice ,joint
pain and seizures
SURGICAL HISTORY: h/o surgery done for midline neck
swelling at the age of 10 years.(No documents or reports available).
TREATMENT HISTORY –
Patient has no history of any medication.

8. • PERSONAL HISTORY – Patient is a hukka smoker since 10
years. He is vegetarian , non alcoholic, normal bowel and bladder
habits.
• FAMILY HISTORY : no such complaint in any family member

9. GENERAL EXAMINATION
• General condition- fair
• Slim built, calm, conscious, oriented
• Weight- 64 kg, height 174 cm
• Pulse- 88/min, regular, normovolumic, all peripheral
pulses palpable ,no radio femoral delay,
• B.P- 123/78mmhg
• R.R- 18/min
• Temperature - Afebrile
• Pallor, cyanosis, clubbing, edema absent,
• No lymphadenopathy.

10. AIRWAY ASSESSMENT
• Oral Hygiene- Average
• Jaw movement and mouth opening – adequate
• MP grade II
• Dentition : no loose teeth
• Inter incisor gap >3 fingers
• Thyromental Distance - > 3 fingers
• Neck extension – normal
• Airway –patent

11. LOCAL EXAMINATION
INSPECTION
Pizzillo’s method was used for inspection of the gland.
On inspection visible swelling was present in lower neck of
size 9 cm x 6cm vertically & horizontally, oval in shape,
irregular surface, defined margins, no visible pulsation with
normal overlying skin
• The swelling moved with deglutition
• It was immobile with protrusion of the tongue.
• No colour change over the affected area.

12. • Second swelling was present in front of right sterno
clavicular junction of size 4cm x 4cm vertically &
horizontally , oval in shape, smooth surface, defined
margins, no visible pulsation with normal overlying skin.
• Patient was asked to raise his hands above the head and to
touch his ears with his arms. Engorgement of neck veins
was absent – Pemberton’s sign negative

13. FRONT VIEW OF SWELLING

14. Swelling in lateral view

15. PALPATION
• Thyroid gland was palpated with the patients neck slightly
flexed.
• The gland was palpated from behind with the thumbs of both
hands placed behind the neck and the other 4 fingers of the
each hand are placed on each lobe and isthmus.

16. Thyroid swelling –
• SURFACE :Swelling was nodular and firm in consistency, non
tender
• POSITION was midline in neck , size 9 x 7 cm
• MOBILITY was noted in both vertical and horizontal planes.
• On applying pressure, stridor and dyspnea was absent –
Kochers Test

17. • LOWER MARGIN of swelling could be reached ( ruling out
retro sternal goitre)
• Cervical lymph nodes not palpable.
• Local temp not raised .
• Carotid pulsations are normal bilaterally

18. Sterno-clavicular joint swelling:
• SURFACE :Swelling was smooth ,uniform and cystic in
consistency, tender
• POSITION was right sterno clavicular junction , size 4 x 5 cm
• MOBILITY was absent
• Temperature was warm
• Pulsations present
•AUSCULTATION: Systolic bruit was absent

19. SYSTEMIC EXAMINATION
1. Respiratory System :
INSPECTION
• No scar mark / lump or skin lesion seen.
• Bilaterally symmetrical
• Chest movement equal on expiration and inspiration
• No indrawing of intercostal spaces on inspiration
• Venous pulses not present
• Respiratory rate – 18/ min

20. PALPATION
B/L equal chest movement
No palpable lymph nodes ,swelling present over neck
Trachea in midline
Normal chest expansion
PERCUSSION
Normally resonant bilaterally
AUSCULTATION
B/L vesicular breathing ,equal, no added sound

21. 2 . CARDIOVASCULAR SYSTEM
Inspection
No deformity of precordium present
No visible pulsation or venous collaterals seen
Apex beat visible in left side just lateral to MCL
No edema present ,no scar mark present
Palpation
Apical impulse palpable in left fifth ICS just lateral to mid
clavicular line
No other palpable heart sounds

22. Percussion
Normal precordium dullness present
Auscultation
Normal S1 and S2
No murmur heard

23. 3. NERVOUS SYSTEM
Conscious, oriented to time place and person

24. 4. PER ABDOMEN EXAMINATION
Inspection : Scaphoid shape ,umbilicus inverted
Palpation : soft ,Non tender, No evidence of any
organomegaly
Auscultation : Bowel sounds heard

25. PROVISIONAL DIAGNOSIS :
• 47 year old male with left lobe multinodular goitre at present
euthyroid with additional swelling at right sterno-clavicular
junction

26. Differential Diagnosis –
• Hashimoto’s thyroiditis
• Colloid goitre
• Papillary carcinoma of thyroid
• Infectious Thyroiditis

27. Final Diagnosis:
• 40 year old male with follicular neoplasm of left lobe of
thyroid at present euthyroid with metastatic lesion at right
sterno-clavicular junction.
Operation Proposed:
• Total thyroidectomy

28. Thank You